HomeMy WebLinkAbout1465A WORKF.RS'COMPENSATIONDECLARATION �aRas�w �
I here6y affirm that I have a certifcate of�o�s�<<oge« <E��„=-.o, APPLICATION FOR PLUMBING PERMIT
insure,or a certiflcate ot Workers'Compensation)nsurance,or � �
a cer,[i�'ied,qypXt}�rgpUSec„AgpO,Lap C.) . .• , _• .
tSb l.R y5b47d I,YNY qetna 5/82 COUNTY oF lOs ANGELES BUILDING A�ID SAFETY .
Poiicy No. � Company � �
� Certified copy is hereby furnished. FOR APPLICAN7 TO FILL IN(PRINT OR TYPE) BUILDING-
� NUMBEH FIXTURE DR ITEM • FEE ADDRESS 500 N� d n
Certified copy it filed with e cou ii ng inspec ion
�Iepartment. WATER CLOSET LOCALITY Diamond Bar
Date Applicant NEAREST
4 BATHTUB � CROSSST. ; C , �
CERTIFICATE OF£X T[ON F ORKERS'
COMPENSA ON INS ANCE . Z SHOWER $ �� OWNEF '
LAVATORY MAIL �
(This section need not be compteted if the wor¢imolved �Q ADDRESS 629 C vi na B d
by the permit is for one hundted doilars (5100)or leu.) �-
4 SINK �,T�San Dimas re�.r,c699-8941 °-
I certify that ln the performance of the work fnr which this 4 DISHWASHER �6 �� CONTRACTOR O
permit is issued,1 sheli not employ any yerson in any menner �
� so as to become subject to the WorAers'Compensation La+vs. CLOTHES WASHER qDDRESS 12061 Pi pel ine Ave �
Date Applicant SWIMMING POOL RECEPTOR
NOTICIi TO APPLJCANT:If,after making this Certiflcate of CITV Ch7n� TEL.N0.6Z7_7rjO� W
Ezemptinn, you should becnme subject to the Wnrkers' LAWN SPFiINKLER SVSTEM STATE LtC. a^
Compensation provisions of the Labor Code,you must forth-
4 WATER HEATER LICENSE NO. . �42274 CLASS C-3G Z
with comply with auch provisions or this petmit shatl be —
deemed revoked. 4 GAS SYSTEM rj OUTLETS �6 0o DISTRICT ND. PgOCE55ED BV
�
LICENS@DCONTRACTORSDECLARATION OU7LETSOVER �0 �l caoc.�ti
I hereby affirm thet 1 am licensed under prorisions of Chapter 5 aeR SvSTEM �
9 (commencing with Section 7000)of Division 3 oC the Rusi- FINAL VALIDATION
ness and Nrotessions Code,and my license is in full force and DaTE �, �y 8"�
effect.
FINAL
Licenx Number 74 Lic.Class C^36 By �,_„
co�„e�,e� Pipeline P1b�e,e 1/28/82
� 1 am exempt from Ihe licensing requirements as 1 am a Pla�check fee
licensed architect or a registered proteuional engineer PLUMBING PERMIT ISSVING FEE S 192 50 �
acting in my Drofessional capacity(Section 7051, Bus- ,
iness and Professions Codt). � TOTAL FEE
Lic.or Reg.No. Date plan oback applicant
}{O11F,OWNF.R-BUILDGIZ DECLARA7ION Name
Addreu �1 4 Q 5 A
1 hereby affirm that I am exempt from ihe Cantractor's ' �
License Law for the following reason(Section 7031.5,8usi• City Tsl.No, � #• �• •�•U �
ness and ProTessions Code): • �
� I,as awner of the property,am ezclusively contracting , � '�,' � 9�.Jr Q
with licensed controttors in construct the project
- (Section 7044,Business and Professions Code). � • • 1 9 2 5 0 ci
WNSTRUCTION LENDING AGENCY O Z O 4—S 2
I fiereby affirm ihat there is a construction lending agency �
for 1he perfnrmance of the work tor which this permit is ,
issued(Sec.3097,Civ.CJ.
� LendePs Name
LendePs Addrets �
!certify that 1 have read this appllcation and itate that the � �
above information is correct.I agree to comply with all County SF.F.REVERSE FOR EXPLANA7'ORY LANGUAGE
rdinsnces and State laws regulating Plum6ing, and hereby
nihorize repres atives of this County to enter pon he �
ave- ption property for inspec' purposes. �
nat re o e ' ee Date ,
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